One of the OSCE stations

Instruction outside the station: Please examine the patient’s heart

 

Me: (Introduction, Some difficulty with exposure as the lady was shy to take off her bra. Then Inspection, Palpation and Auscultation, then turned to examiner)

 

Examiner: Are you finished?

 

Me: Yes, I think so.

 

Examiner: Are you sure? No other examination to do?

 

Me: Yes, I am sure.

 

Examiner: Ok. Present your finding.

 

Me: On inspection, the lady looks comfortably at rest with some malar flush on the face. On inspection of the precordium, there is a median sternotomy scar. On palpation, there is no parasternal heave or thrills. On auscultation, I can hear an ejection systolic mummur loudest in the aortic area radiating to the carotids, There is no basal crepitation or peripheral oedema.

 

Examiner: Anything else?

 

Me: I think I heard a prosthetic valve click as well.

 

Examiner: Which valve?

 

Me: I’m not sure.

 

Examiner: What do you mean you are not sure? Did you listen with your stethoscope?

 

Me: Yes…

 

Examiner: Well? Do you know how to listen with your stethoscope?

 

Me: (A little taken back by his rudeness!) Yes, I do know. I think the click was loudest in the mitral area. 

 

Examiner: Only the mitral area?

 

Me: Well, I think so. But I think there is definitely two separate clicks on each of the first and second heart sounds, especially at the aortic area.

 

Examiner: So you heard clicks on the mitral and aortic area?

 

Me: Yes.

 

Are you saying that this patient has a combined aortic and mitral prosthetic valves?

 

Me: Yes.

 

Examiner: Good. Thank you. You may leave.

 

 

After being mocked on my auscultating skills, I was sure that I have failed this station. Turned out to have been award 6/7 for this station! The examiner had just put the diagnosis into my mouth. Luckiest escape ever. Just had to keep saying yes. :)

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Comm skills deception

I'm annoyed today. We (the fifth years not on elective in my hospital) were sent an email a while back telling us that we have to attend a mandatory communication course on health promotion. We were warned that if not we will be sent to the hospital dean to explain ourselves.

So I left the morning clinic at Wigan early to take a train to Manchester then another bus to Hope Hospital where it was held. I had to rushed all the way and reached just on time. Then I heard people around saying that it was apparently not mandatory.

After that the people running the course came in to start. What a surprise to be told that we were actually the guinea pigs for this course that they are only piloting and we were expected to fill in stupid long questionnaires before and after the session for evaluation and research purpose - our response would tell him if they should THEN make it mandatory to students in the year below us. They also had the cheek to ask for volunteers on the spot to be tape recorded for some psychology dissertation. Normally medical students are quite willing to help out with experiments, but they have gone too far this time. Only 4 out of the 25 or so there volunteered (later 2 others came forward - ?out of sympathy - I don't think they deserve it).  

It's unfair. I was raging because I felt duped into coming. I pulled a 'black face' throughout the three hour session. Luckily my group tutor was obviously not a fan of communication skills teaching business (as much as he tried to hide it). Didn't stop me from complaining. Do they realise how time consuming and expensive it is to travel to the teaching hospital when you are based on a district general? The journey that would normally take 30 minutes by car took 2 hours by public transport, and cost me £6.60 (I spent a ridiculous £13.40 on that day just on public transport!). Do they care?

I didn't find the course useful. I found it painfully patronising. My colleagues, maybe out of politeness albeit with a doubtful tone, said it was useful, but would have preferred a three hour teaching on neurology instead. My tutor remarked that he also would have been more comfortable with teaching us neurology for the last three hours.

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The Finishing Line

The few weeks towards the exams were the worst. I did not do any revision over the Christmas holiday. I did not develop enough sense of urgency to start revising yet. I remember thinking what else it is that I could possibly not know? I kept on telling myself to open the books and start memorising things, but I was much more interested in Doctor Who and the whole lot of tantalizing festive programmes on TV. The intensive revision really only started on the 3rd of January (and my exam starts on the 13th), when the medical school's revision lectures started. It turned out that there were indeed many things that I still do not know, but the rest of my year does, which was scary. I learnt and memorised more things that I've ever had in the 10 days. As with the previous exams, I felt I was never going to have enough time to cover all I wanted and wished that I'd started earlier (and always promised myself that I would start revision earlier next time but I have never fulfilled this promise before). I was also doing practice questions and found out even more things that I apparently should know but didn't. I was consistently getting 60-70% while I expected nothing less than 80% by that stage, so it worried me.

Then there is the pressure. This is THE exam. I pass, I'm a doctor; I fail, I'm not a doctor. During the OSCE, I thought of how unfair it is that all our doctoring skills that we have learn in the 5 years be judged in merely 2.5 hr by strangers who never knew us. There were too many people that I didn't want to let down. My parents - they have been very supportive with plenty of encouragement. They also went to the temple and prayed for me. They and my sisters were really the only people that I could talk to about how stressed I was, but I tried not to because it would make them worry and feel helpless. Then there were the two senior doctors in the Chorus with me. They were each my consultant and tutor previously and I know that when I return to rehearsal in the new term, they would go 'So?' with regards to the finals. Last year, I was told that only 3 out of the 20 Malaysian students passed the exempting exams, making me feel worse.

I don't know why, but people always say to me 'Don't worry Yee Yen you will never fail. If you fail, what hope has other people got?'. If they have realised that I just wasn't as good as I used to be, they will understand why I was so genuinely worried for a very real possibility of failure. I messed up my PMP - It was in a difficult format and I didn't know the answer to half of the questions. Throughout January until the result was released, I was an emotional wreck. I would burst out in tears for no good reason, and go on crying for hours, drowning in self pity. It was worst after the OSCE as I was convinced that I failed. In the morning of the OSCE, two buses wouldn't take me as I didn't have small change (but the third bus driver let me on without charge). I took it as a really bad omen and just spent the whole 20 minutes journey on the bus crying. As a result, I was a few minutes late for reporting. I wasn't myself throughout the OSCE. I did well in two or three stations (managed to keep my hands at the back and looked professional because I knew my stuff) but the rest stations were either average or bad. I managed to make silly mistakes like not requesting a pregnancy test for ?ectopic. I wouldn't disagree if the examiners thought I wasn't fit to pass. Very sad. I was supposed to pick myself up quickly for the last paper in 2 days time, but I couldn't. I did some revision eventually, but I didn't put in full effort as I thought, what's the point, I've already failed. Luckily, the progress test wasn't as bad.

After the exam, we went out to eat and had a good rant. It made me feel better, but still I needed to prepare myself for the results. I have a plan of what I would do for the resit. I would get two revision books, do lots of practice questions more consistently and prepare for past year OSCE questions. I told my parents not to expect good news. While I was in London, I also told my sponsor that its likely that I'd have to resit. I was travelling from London back to Manchester on the day the result was due to be released at 1pm. When I booked the coach, I thought should I arrive at 1 or 2? I settled for 2pm. The later I know, I less pain I'd suffer. But as I arrived in Manchester, I found myself rushing back home to check my results on the internet. (But at the same time still reminding myself to not get too excited as I'd only be disappointed after).

'Year 5 Exempting Examination Results' was the first announcement. I opened the announcement, clicked on the Y5_Exempting_Results_Grid_Jan_10 pdf file, scroll through to find my library card number, and read carefully.

PMP and PT - H

OSCE - S

Outcome -Pass - Exempt

What?! Hah! I closed it and opened it again. It was the same. It was only then, I dared to think about actually being a doctor! I PASSED THE FINALS!

I won't make an Oscar speech here but I'd just like to say how grateful I am to have such a wonderful family. Mummy, we are the product of your sacrifice all these years and you are responsible for the person I am today. This is your success as much as it is mine. I think you have done a great job!

My friend had written a more detailed account of the OSCE exam here. It's very brave of him to reflect so openly. I can't, I'm still suffering from the post traumatic stress...

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The Road to Finals

I am going through an anticlimax. It was not a short battle, so I do not expect this to resolve in a blink. Let’s recollect.

Finals. Every final year medical students start worrying well before the beginning of final year. This is the most important exam in medical school. Everyone know it, the students, the teachers and even some of the patients!

I started thinking about it much earlier. For a while in my third year, I was very confident with my own ability. Although I was just as disorientated as my fellow friends who have just started the clinical year, I worked much harder then many of them. I was often ignored in wards and clinics but I persevered, always with the endless questions and getting excited over new things I learn everyday. The effort paid off. I was better than my friends and even some junior doctors. I thought I would pass finals easily even if I was thrown into the final exam then. But I also felt increasing alienated by my friends for being different. I was always alone because no one shared my enthusiasm.

So although I still see patients more often than my friends, subconsciously, I toned down this obsession in my forth year. The relationship with my friends improved. But the medical side of things suffered. I was average and did not always have the extra bits to contribute in group discussion like I had in my third year. All in all, fourth year was a fantastic year, although by then I was no longer boosting with confidence like I used to.

Fifth year started badly with disappointment over my research project not being accepted for presentation in a meeting that I was really looking forward to attend. I felt crossed because people were full of praise about my work. Have they just been lying to me all these while to make me feel good? For a whole month, I buried myself under the duvet. There was a background worry about finals but I just did not have any motivation to revise. My supervisor’s ex-students had always managed be accepted for presentation in those meetings in the past, I am the only stupid one. I felt as worthy as a piece of dirt on the floor. I hardly told anyone about this because I felt so humiliated. Then, on the next placement with the geriatric firm, I was surrounded by patients again and felt better as I was a valued member of the team.

The GP placement made me rethink my clinical knowledge. I saw many patients on my own but was only confident with the diagnosis and management in less half of them. I would never forget the instance that I made a diagnosis of biliary colic even though in the history I knew that she had lost 20 kg in a short space of time. My GP was critical that I have not referred her urgently to the hospital. How lucky she was that I wasn’t yet a real doctor. I saw her scan later - she had widespread cancer all over her liver. I used to think ‘worst-case scenerio’, but in GP land, as common things are common, I sometimes forgot to think through the wider list of differential diagnosis, instead I tried to make it fit into benign story. It scared me and rocked my confidence level big time. To imagine that I have to be able to figure out what’s been wrong with every patient that comes through the door and be able to initiate treatment is horrifying. I am not ready to be a doctor. I am not going to pass finals and maybe I don't deserve to.

On the other hand, the gap in knowledge in the whole year group narrowed and we all knew the same thing more or less by then. My extra effort in the early years was null as everyone else have caught up. I was definitely not top of the class anymore. I didn’t know what else I could do to raise my game. So, well into my fifth year and I am well blended with the rest of my friends academically and socially, yet I am not a bit confident to be a doctor.

TO BE CONTINUED…


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